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;an Joaquin County <br /> FILE/ � Y <br /> a gffi� Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web : www. sjgov.org/ehd UNIT IV <br /> <rFoR�`P Well Permit Application CCCc p�R1� �7 g ss�� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM @89j NAW�O PM 2* 52 ` <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. . This ap Iioat'gqnn ��ss made in compliance with San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin Count��rkiroodmerlwlf �i ail a4hfient. <br /> - ' �� r, t 1 ' ' t, ' cL � i 1t1 t , Assessors <br /> p <br /> WELL Location 103 We C6,( W (�.Y Cross Street IvU�r Cily$PW�'� l� cFr"Lf}� ' r , 1j Parcel# 16 � -aJv ` <br /> PROPS BT <br /> Owner OpG�gJty I'/II IUY To Address � I3�} Uncoln Rou.� City� fVn�"� un Zip VIPhone�j# <br /> C-57 ContractortrflVty0T1r0 & AddressV tY o1 f lOI.�,-2 aaCity Vfc1�. I/ rr Zip� �V Lic# (7K02Z7 '_ Phon# tea - J77 " 4g3b <br /> Consultant / Sub Cntr/-11AVay)(LIl l?4O 1`1 (011Vl1�a4Wdress 85) Si &UJ QOaJ CityS baj[W` Lic# Phone# 20 '461 -006 <br /> GIS Coordinates: X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> T NEW WELL / BORING (CPT, GEOPROBE, YDROPUNCH , HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br /> ISOIL BORING # 12522— DOVER-BORE . DIAMETER <br /> WELL # n PRESSURE GROUT <br /> p *Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA. OF BOREHOLE lin a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC Q OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL (P00 TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br /> 0 AIR SPARGE/ OZONE PUSH POINT (GP or CPT) GROUT SEAL PUMPED: p Yes )Z No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> [ SOIL BORING a HAND AUGER GROUT SPECIFICATIONS -I�i1�2- l � I t 1�ur IGv�4 <br /> p OTHER: p OTHER APPROX. BORING DEPTH V, O 1 p BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES , list specifications in comment section) <br /> COMMENTS: <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS, <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances , Rul nd Regulations , and all applicable California SState L''a^ w��js. //�� �__ �� � � (� <br /> Signed Title/Company Nyanl_ tK.(Il. Gc'o [%j \ll (d VIIyy'QAA �LIX <br /> Print Name A \ Kuy Del C "�- r. Date 30 ` )L � G <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : <br /> WORK PLAN DATED : <br /> Application Accepted By Date Issued / � ` 0 Area Q <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS : <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNTREMITTED CHECK # REC'D BY DATE PERMIT I SERVICE REQUEST # INVOICE <br /> T z 36Fr ' ?�{ 08 - � SR# <br /> C-57.L WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encro Hent doc I;/ ` ' <br /> EHD 29-02-001 Q�4.P. <br /> n P�-'.�P <br /> 6/22/04 l� <br />